Twin Lakes Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Jennifer Flores. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator thermometer at 40 F and Freezer thermometer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 7/1/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 7/8/2025. LPA toured 8 resident bedrooms. All 8 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 5 resident bathrooms. All 5 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 115.5 F to 119.4 F. Page 1 of 2 LPA reviewed 3 resident records. LPA reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. During the tour of the facility, LPA observed video surveillance cameras in the facility. Based on observation, the video surveillance monitors different locations of the facility to include the hallways, front lobby, dining room, living room, and front of the facility. ADM stated he/she is not sure if the video surveillance was part of the facility's plan of operation. ADM stated the video surveillance camera have audio recordings. LPA advised ADM that video surveillance cannot have an audio component. LPA advised ADM to disconnect the audio component of the video surveillance. ADM disconnected audio component of video surveillance during inspection. ADM to collaborate with LPA regarding facility video surveillance. LPA provided ADM with a copy of PIN 25-06-ASC. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator (ADM) Jennifer Flores and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

Allegation investigated: Facility interfered with resident's access to hospice services. Unlawful rate increase.

On 3/1/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unanounced at this facility to conduct a follow up complaint visit regarding the allegations noted above. LPA initially met with staff on duty and stated the purpose of the visit. The administrator, Jennifer Flores, was notified of this visit and arrived shortly after. Present during today's visit were 7 residents in care with 3 staff on duty. Allegation of Facility Staff Interfering with Resident's Access to Hospice Services: The allegation centers on the claim that facility staff interfered with resident (R8) access to hospice services. The investigation into this allegation consisted of interviews and record reviews. {1 of 3} Unsubstantiated Allegation of Facility Staff Interfering with Resident's Access to Hospice Services (con't): In an interview with the facility administrator, Jennifer Flores (AD), it was disclosed that there has been ongoing tension with R8's family member, F1. AD explained that F1 has been in frequent conflict with staff and hospice nurses, particularly disputing R8's medical conditions and care needs. AD indicated that F1’s behavior was a key factor in R8 being removed from hospice services, as hospice nurses reportedly found it difficult to work with F1. Specifically, F1’s objections to the care plans and medical recommendations, including the administration of seizure medication for R8, contributed to the nurses' decision to discharge R8 from their services. AD clarified that while F1 wanted R8 to be placed on hospice, the hospice nurses did not agree, as they did not consider R8’s condition to be severe enough to require such services. AD further stated that she had no input in the decision to place R8 on or off hospice, as this was solely determined by the hospice providers. Despite F1's desire for hospice services, AD noted that R8 had been evaluated multiple times, and each time, hospice nurses concluded that R8 did not meet the criteria for hospice care. A review of the records shows that R8 was discharged from Palliative Care Services on 11/18/2022, which aligns with AD's account that hospice services were withdrawn. This decision was reportedly based on the hospice nurses' assessment that R8 did not require hospice care. Additionally, AD mentioned that she had been actively working with the Ombudsman and hospice staff to address F1's concerns and ensure that R8’s medical needs were being met. However, F1 reportedly disregarded the facility's reports and recommendations, often expressing dissatisfaction and accusing the facility of withholding proper care. Based on the gathered information, this allegation was UNSUBSTANTIATED. While there were conflicts between the facility and R8’s family member, particularly regarding R8's care and the provision of hospice services, there is insufficient evidence to support the allegation that facility staff interfered with R8's access to hospice. The decision to discontinue hospice services appears to have been made by the hospice nurses. ************************************************************************************************************************** Allegation of Unlawful Rate Increase: The allegation involves a potential unlawful increase in the cost of care for resident (R8), particularly concerning changes in R8’s care fees and related services. The investigation into this allegation consisted of interviews and record reviews of relevant documents. {2 of 3} Allegation of Unlawful Rate Increase (con't): In an interview with the facility staff explained that R8's care needs had increased, which led to adjustments in their care plan and service charges. Initially, R8 was receiving level 1 care, but as their needs increased, the facility reassessed R8’s care requirements, resulting in a higher service rate. Staff stated that this increase was in line with R8’s changing medical condition and the need for additional services, including hospice care, which was also part of the rate adjustment. Staff noted that R8's family member, F1, had expressed dissatisfaction with the facility's decisions, particularly regarding hospice services and the associated costs. A review of R8’s care plans from May 2021 and October 2022 confirms that there was an increase in both the care level and the cost of services. The care cost for R8 rose from $2,278 per month in May 2021 to $5,618 per month in October 2022, corresponding to the increase in care requirements. Additionally, a written notice provided to R8’s responsible party indicated that, effective 12/29/2022, the care rate would increase from $4,682 to $5,618, again citing the increased care needs. This notice aligns with the terms outlined in the facility's admission agreement, which specifies that the facility may adjust the rate of care services immediately if the resident’s needs change. The facility’s admission agreement, signed by F1 on 6/6/2021, includes provisions for rate adjustments under Section 4(a), which states that the monthly rate for core services may be changed upon 60 days' notice, with adjustments reflecting changes in care needs. This agreement also provides for an annual rent increase of up to 4%. Additionally, it is outlined in the agreement that hospice services, if requested, would incur an additional fee of $700 per month, on top of any other applicable charges. Furthermore, an examination of R8's rent history shows that the facility provided a written notice of a rent increase from $1,950 to $2,028, effective 8/1//2022. This increase is consistent with the facility’s practice of annual rent adjustments, as outlined in the admission agreement. In conclusion, the increase in R8’s care rate appears to be in compliance with the terms outlined in the facility's admission agreement, which allows for adjustments based on changes in care needs, with proper notice provided to R8’s responsible party. Therefore, this allegation was UNSUBSTANTIATED. A finding that is unsubstantiated means that there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview was conducted and a copy of this report and appeal rights were provided. {3 of 3} Allegation of Injury Sustained by Resident (R8) While in Care According to staff interview, R8 has a history of seizures, which appear to be short and atypical in nature, describing these seizures as involving a brief loss of motor function, with R8 freezing, rolling their eyes, and occasionally raising their arms before returning to baseline within 3-5 seconds. Staff noted that these episodes can occur during ambulation, potentially causing falls. One such fall involved R8 hitting their head after a seizure while walking, resulting in a hospital visit. Staff indicated that R8’s family member, F1, has been frequently argumentative about the resident’s care, particularly concerning R8’s medical diagnosis and treatment, including the administration of seizure medication and recommendations for hospice care. F1’s behavior has reportedly led to the discontinuation of hospice services for R8, as hospice nurses found it difficult to work with F1. Despite this, staff has consistently reported changes in R8’s condition to hospice and other involved parties, keeping a detailed paper trail with the Ombudsman and hospice staff. Staff member S2, who works the 3 PM to 11 PM shift, confirmed an incident on the night of the fall. Although S2 did not witness the fall itself, S2 heard it and responded immediately. Upon entering R8’s room, S2 observed a cut on R8 head and noted that R8 appeared stable. S2 cleaned the wound and ensured R8 received further medical care after. S2 also communicated the incident to AD, who later instructed R8’s familiy member to take R8 to the hospital. S2 reported that while R8 was somewhat more confused than usual that day, he did not appear severely injured or bruised initially. S3, another staff member, corroborated that R8 does not often fall and has a history of seizures but was unsure of the specific causes of these episodes. Reviewing the facility’s incident reports provides additional context. On 12/11/2021, R8 fell, resulting in a skin tear on right arm, but he did not report pain and was transported to the hospital for evaluation. Another fall occurred on 2/10/2022 while R8 was in the bathroom, leading to an unwitnessed fall with a resulting wound. A third report on 11/16/2022 indicated a fall with a minor bruise to R8’s upper right brow, and the Palliative Care Nurse was contacted to report the incident. {2 of 3} Based on the available information, R8’s falls appear to be linked to their medical condition, particularly seizures, which can cause temporary loss of motor function during ambulation. The most recent incident, which resulted in a head injury and subsequent medical treatment, underscores the risks associated with R8’s condition. Based on the gathered information, this allegation was SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met. However, while the resident’s fall and injury are concerning, they appear to be a result of his medical condition, which is known to cause brief seizures that can lead to falls. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. During exit interview, LPA discussed plan of correction with Administrator; a copy of this report and appeal rights were provided. {3 of 3}the state’s words, verbatim · CDSS document, Mar 1, 2025 · control 26-AS-20221103122231

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Mar 8, 2025

87464(d) Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... This requirement is not met as evidenced by: Based on interviews and record reviews, R8 sustained injury from fall incidents which may be due to medical condition. This poses an immediate health, safety, and personal risks to persons in care.the state’s words, verbatim · CDSS document, Mar 1, 2025

Plan of correction: Per discussion, Administrator (or Licensee) will develop a plan on how to mitigate/lessen residents falls and sustaining injuries and submit plan to LPA via email by POC date.

Allegation investigated: Staff sleeping in resident's room during a shift. Inadequate staffing to meet the needs of the resident's in care. Facility not providing activities to residents.

On 1/19/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unanounced at this facility to conduct a follow up complaint visit regarding the allegations noted above. LPA initially met with staff on duty (S1 and S2) and stated the purpose of the visit. The administrator, Jennifer Flores, was notified of this visit and stated she is not available to come come to the facility to assist with this visit but gave permission to either of the staff on duty to assist LPA and sign this report. Jennifer is availbe via phone if needed. Present during today's visit were 7 residents in care with 2 staff on duty. Today's visit, this LPA conducted additioinal record reviews and facility observations. LPA also obtained copy of additional documents for further review. {1 of 3} Unsubstantiated Allegation: Staff sleeping in resident’s room during a shift. The investigation into the allegation of staff sleeping in a resident's room during a shift consisted of interviews and observations. Interviews with the facility administrator and staff members indicated that staff members are attentive and present during their shifts, with no evidence of staff sleeping in resident rooms. Administrator Jennifer Flores confirmed that there is no live-in staff at the facility, and the staff schedule shows that there are two staff members on duty during the day and evening shifts, with one staff member on the night shift. Staff members that were interviewed reported that they remain attentive to residents' needs throughout their shifts, ensuring residents receive the necessary care and attention. During the site visit on 11/23/24, LPA observed two staff members on duty, and there was no indication of staff being inattentive or sleeping in any resident room. Additionally, a review of past inspection reports made from the Department, dated 11/23/24, 9/12/24, 11/19/22, 8/3/22, 3/9/22, and 9/17/21, did not reveal any evidence of staff sleeping in resident rooms. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Inadequate staffing to meet the needs of the residents in care. The investigation into the allegation of inadequate staffing to meet the needs of the residents in care consisted of interviews, record reviews and observations. Interviews with the facility administrator and staff members indicated that, despite occasional challenges related to staffing shortages, the facility generally maintains an adequate number of staff to meet the needs of its residents. The administrator, Jennifer Flores, acknowledged that there are times when staffing is reduced, particularly in the night shift, where only one staff member is on duty. However, staff on the day shift reported that they are able to meet the residents' needs effectively, even with minimal staffing at times. Furthermore, interviews with staff confirmed that there are typically two staff members on shift, and they manage to attend to the needs of the residents, who generally do not have very high care needs. Additionally, staff stated that while there was a temporary staff shortage due to resignations, they are still able to attend to residents and manage their care, including addressing toileting needs. Furthermore, during the site visit, LPA observed two staff members on duty, residents engaging with staff in the living room, and no indication of staff being overwhelmed by residents’ needs. Despite having short staffing issues in the past, it is unclear that the facility was inadequate to meet residents’ needs. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. {2 of 3} Allegation: Facility not providing activities to residents. The investigation into the allegation that the facility is not providing activities to residents consisted of interviews, record reviews and observation. Interview with the facility administrator, Jennifer Flores, confirmed that the facility has an activity schedule in place, with daily activities planned from Monday to Friday. The weekends are left open, as this is when families typically visit and take residents out. The facility also has activity supplies available, which were observed during the site visit on 11/23/24. Additionally, staff members indicated that they attend to residents' needs, including those who participate in activities. While the administrator acknowledged that staffing shortages sometimes impact the consistency of activities, the facility does make an effort to follow its activity schedule. On the day of the visit on 11/23/24, residents were observed engaging with staff in the living room, watching TV, and conversing. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Based on today's visit, no deficiencies are being cited. Exit interview was conducted with Jennifer Flores, Administrator, via phone. S2 signed this report. A copy of this report and appeal rights were provided. {3 of 3}the state’s words, verbatim · CDSS document, Jan 19, 2025 · control 26-AS-20221103122231

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin, Manuel Monter, and Santino Fortes arrived to conduct a 1 year unannounced annual inspection. LPAs met with Administrator (ADM) Jennifer Flores. The facility serves elderly residents, 60 years and older, and all residents may be non-ambulatory. LPAs toured the facility inside and out with the Administrator to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and backyard. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen and dining room. Facility has 7 days worth of nonperishable foods and 2 days worth of perishable food supply. Refrigerator temperature maintained at 48 degrees F and freezer temperature maintained at -0 degrees F. LPAs toured 2 out of 2 hallway bathrooms. Hand soap, paper towels and functioning lights in 2 out of 2 bathrooms observed. Water temperature in 2 out of 2 hallway bathrooms measured at 118 degrees F. LPAs observed tags on fire extinguishers with an inspection date of 6/24/2024. ADM tested the carbon monoxide detectors and were observed to be operational. LPAs toured 8 out of 8 resident bedrooms. LPAs observed 7 out of 8 resident bedrooms to have clean bedding, functioning lights, storage space for belongings, a chair and a dresser. At 10:10AM, LPAs toured R1's bedroom and noted a strong malodor. LPAs observed blood on R1's top bed sheet (photograph was taken). ADM states R1 has been scratching herself since admission (10/28/2020). ADM states both R1's Power of Attorney (POA) and physician are aware of the residents behaviors. LPAs advised ADM to remove bloody bedding and replace with clean bedding. LPAs reviewed 4 residents Centrally Stored Medication and Destruction Records (CSMDR). LPAs observed 4 out of 4 CSMDRs are complete with all medications documented. See LIC809C. LPAs reviewed 4 resident records. Based on records reviewed, Resident R1-R4 have a neurocognitive disorder. Based on review of the R1-R4 needs and services plan, the plans have not been updated annually. LPAs requested copies of the Physician's Report and Needs and Service Plan for R1-R4. LPAs reviewed 4 staff records. LPAs observed 4 out of 4 staff records as complete. 4 out of 4 staff obtained fingerprint clearance, annual training, health screening, TB result, personnel record, and employee rights. LPAs interviewed 3 staff and 3 residents. LPAs requested to review facility's disaster drill logs. ADM stated she conducts drills annually, with the last drill conducted on 10/3/2023. Deficiencies were cited today per California Code of Regulations Title 22. See LIC809-D. This report was reviewed with Administrator Jennifer Flores and a copy of the report and appeals rights were provided. END OF REPORTthe state’s words, verbatim · CDSS document, Sep 12, 2024